435202907-9-25-2025-26-AS-CKAI-DLUNWA-20250925104913

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202907
Report Date: 09/25/2025
Date Signed: 09/25/2025 10:49:22 AM

Document Has Been Signed on 09/25/2025 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	CALIFORNIA MENTAL HEALTH LLC		FACILITY NUMBER:	435202907
ADMINISTRATOR/ DIRECTOR:	CISNA, DEREK		FACILITY TYPE:	772
ADDRESS:	14865 MARIE COURT		TELEPHONE:	(949) 836-6793
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 6		CENSUS: 6	DATE:	09/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Program Director, Josh Fane		TIME VISIT/ INSPECTION COMPLETED:	10:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Program Director (PD), Josh Fane. During visit, LPA toured the facility with the staff to include the living room, kitchen, 4 resident bedrooms, 3 bathrooms, group room, medication room, garage, backyard, and storage units in the backyard that are being used as office spaces. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. There are cameras throughout all common areas and exterior areas of the facility. Facility temperature maintained at 73 degrees F. The facility has a central air-conditioning system that was in use. Fire extinguishers last serviced on 04/21/2025. Facility has a dual smoke and carbon monoxide detector that was tested and observed operable. There were multiple first aid kits throughout the facility for use. Medications and sharp objects observed locked. Resident bedrooms equipped with proper furniture to include beds, linens, night stands, closet space, and adequate lighting. Around 08:55AM, LPA measured hot water temperature in 3 out of 3 bathrooms which measured between 132.2 - 134.6 degrees F. PD stated that the hot water heater was replaced about 2 - 3 months ago. PD stated to have measured the hot water temperature after the heater was installed and the temperature was measured within regulations. During visit, PD lowered the hot water temperature. At 10:22AM, the hot water was measured at 120.9 degrees F. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CALIFORNIA MENTAL HEALTH LLC	FACILITY NUMBER: 435202907
	VISIT DATE: 09/25/2025

NARRATIVE

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The facility is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Drinking water available for the clients, when needed. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 39 degrees F. Freezer temperature maintained at 0 degrees F. Weekly menu posted on the refrigerator. Toxins and chemicals stored separately from the food supply.

The backyard is equipped with a shaded seating area. There is a swimming pool in the backyard which contains a secured and locked fence that is about 5 feet high. Refrigerator temperature in the garage maintained at 32 degrees F. Freezer temperature in the garage maintained at 0 degrees F.

LPA reviewed 3 resident files with the PD. 3 out of 3 resident files observed complete and up to date to include an admissions agreement, physician's report, TB result, signed appraisal/needs and services plan, consent forms, personal rights, safeguard of personal properties/valuables, and identification and emergency contact information. 3 residents centrally stored medications and centrally stored medications were reviewed with the staff, and all medications were accounted for.

LPA reviewed 4 staff files and observed them to be complete. 4 out of 4 staff obtains an active first aid certification, fingerprint clearance, health screening, TB result, LIC501 and annual training records. LPA observed staff are provided on-boarding training upon hire and in-service training monthly to include topics (not limited to) crisis interventions, medical emergencies, emergency disasters, medications, infection control, and safe food handling.

Emergency drills are completed quarterly and the last drills was completed on August and September 2025. Facility has emergency supplies to include non-perishable foods, extra flash lights. and batteries.

Documents were requested to update the facility file to include by Friday 10/03/2025: Lease agreement, LIC400, surety bond, LIC500, LIC308, and administrator certificate. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Program Director, Josh Fane and Administrator Jeannie Anderson a copy of the report were provided. Page 2 of 2.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC809 (FAS) - (06/04)

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